Friday, August 31, 2012


Syracuse boy named Shriners Hospitals national ambassador
Double amputee • Hunter Woodhall competes on school teams, always pushes limits.
Thanks to Shriners Hospitals for Children, Hunter Woodhall has lots of legs to stand on.
The 13-year-old has his daily legs, running legs and wrestling legs.
The Syracuse Junior High eighth-grader is active — a scenario that didn’t seem likely after he had both feet amputated at 11 months old. His desire to push any limits set before him was one of the reasons Shriners Hospitals for Children selected him as a patient ambassador for 2012-13. The announcement was made on July 4 during the Imperial Session of Shriners International Convention in Charlotte, N.C.
Every year, Shriners Hospitals for Children chooses two patient ambassadors to represent the thousands of children who receive care at the system’s 22 facilities annually, regardless of their ability to pay.
Mike Babcock, spokesman for the Salt Lake Shriners Hospital, was one of the people who nominated Hunter for the international position and was thrilled when he was selected.
“Hunter is just a wonderful kid. He has a great attitude. He has excelled in academics and athletics. Hunter embodies what we hope to do at Shriners, which is take care of kids and help them reach their full potential,” Babcock said. “We have done numerous surgeries and fit him with state-of-the-art legs, and he has stepped through every door and excelled. We offer every one of our patients the opportunity to excel and participate in every activity. When you have a kid like Hunter, who wants to push it, we will use all our means to take it to that level.”
Hunter was born with serious problems with his ankles, lower legs and feet. He was missing part of an important bone, and his ankle was fused. A team of expert orthopedic doctors at the Tampa, Fla., Shriners Hospital told his parents Hunter’s best option was to have both feet amputated. Still a baby, Hunter had the surgery and shortly afterward was fitted with prosthetics.
Hunter’s family moved from Tampa to Spokane, Wash., and then settled in Utah, where his father is in the Air Force.
Not having feet hasn’t stopped Hunter from playing sports. With the support of his parents, the help of Shriners Hospital and a whole lot of energy, Hunter is always on the run. He is on his school track, football and wrestling teams. In addition, he plays basketball, snow skis, inline stakes, swims and hunts.
Hunter’s wrestling legs don’t actually have feet.
“I have my normal prosthetic, which is for most sports, and then I have one for wrestling and swimming and one for track. My wrestling leg doesn’t actually have feet. My feet are too hard, so it’s like a foam liner,” he explained.
“When I wrestle someone new, they sometimes give me a look, and a lot of people ask me about them. I explain, and then I tell them not to go easy on me, and they don’t,” Hunter said.
Hunter has fond memories of Shriners throughout his life. His first memory involves a stuffed cat the doctors gave him. “I carried that cat everywhere.”
He also remembers the first prosthetics he picked out.
“I was 4, and they were blue and had frogs all over them. I liked crazy things, and they were colorful,” he said. Hunter’s tastes have grown more sophisticated with age, and his prosthetics now are all about function.
Hunter said that being an amputee has not kept him from doing anything he wants and has given him the opportunity to do things he wouldn’t have — like being an ambassador and public speaker and traveling for Shriners.
His mom, Barbara Woodhall, is excited about the opportunity to spread the word of Shriners’ good deeds. She said Hunter has been an unofficial spokesman for Shriners, meeting with other patients and going out and speaking whenever asked. Now in the official capacity, his responsibilities will grow and will include attending the Justin Timberlake Golf Open in October and the Rose Bowl Parade in Pasadena.
“I am excited to share what Shriners has done for me and millions of others because I love them,” Hunter said.
Twitter: @sltribDavis

© 2012 The Salt Lake Tribune

Thursday, August 30, 2012

Overhauling Nursing Education

Laura A. Stokowski, RN, MS
Posted: 01/28/2011
Nursing education is a sizzling hot topic right now. Maybe this is fitting, for 2010 was the centenary of Florence Nightingale's death, and she was the founder of the formal nursing school. The whole profession of nursing is under the microscope, as hundreds of experts and stakeholders study where nursing fits in and where it's going in the era of healthcare reform. However, the foundation of any profession, including nursing, is how its newest members are educated. This article will explore several questions about nursing education, and discuss the recommendations from the recent Future of Nursing reports[1,2] to address these issues.
  • What's missing in nursing education?
  • Are there better ways of teaching/learning?
  • What does future hold for nursing degrees (including the associate's degree)?
  • Does nursing education prepare nurses for practice?

The Rise of "Modern Nursing" Education

If you had just been accepted to nursing school near the end of the 19th century, your nursing courses would be designed to teach you these fundamentals of nursing care:
  • The dressing of blisters, sores, burns and wounds; the application of fomentations, poultices, cups, and leeches;
  • The administration of enemas;
  • The management of trusses and appliances for uterine complaints;
  • The best method of friction to the body and extremities;
  • The management of helpless patients: making beds, moving, changing, giving baths in bed, preventing and dressing bedsores, and changing positions;
  • Bandaging -- and making bandages, rollers, and splints;
  • Preparing, cooking, and serving delicacies for the sick;
  • Practical methods of supplying fresh air, warming and ventilating sick-rooms;
  • Keeping all utensils perfectly clean and disinfected; and
  • Making accurate observations and reports to the physician of the state of secretions, expectoration, skin, pulse, appetite, temperature, delirium or stupor, breathing, sleep, condition of wounds, eruptions, formation of matter, effect of diet or of stimulants or medicines.
This was the proposed curriculum for a school of nursing opening in Chicago in 1882.[3] This curriculum would take a little more than 2 years to learn, during which you would work 7 days a week, 12 hours a day, with 1 afternoon off per week. You would work without pay, essentially as free staff for the hospital; your "salary" was your education. After work in the evenings, you would attend lectures given by physicians or supervising nurses on subjects such as obstetrics, surgical emergencies, anatomy, physiology, electricity, materia medica (pharmacology), bathing, and massage. Exams on these lectures would be given periodically. However, the overall program emphasized practice over theory -- with practice commanding a 90% share of your time.
This, or something very like this, was how nurses were "trained" at the beginning of the era known as "modern nursing." Nursing education followed an apprenticeship model, wherein students took care of patients under the supervision of more senior nurses.
Nursing education received a much-needed boost in 1917 when the National League for Nursing Education published their first standard curriculum for schools of nursing.[4] A more recognizable nursing curriculum, it was organized around the familiar categories of medical nursing, surgical nursing, obstetrical nursing, nursing care of children, and so forth. Student nurses would still have to learn cookery, hospital housekeeping, and massage, but they would also receive classes in ethics, psychology, professional issues, and history of nursing, and could take electives in public health or administration. The underlying theme of the curriculum was that nursing was a profession.
With the appearance of college-affiliated nursing programs and the baccalaureate degree, nursing students had the benefit of an entire university or college with which to supplement their education. For the most part, however, the core nursing curriculum continued to revolve around the traditional medical specialties of medicine, surgery, obstetrics, pediatrics, and mental health.

Curriculum Revolution

In 1988, the National League for Nursing (NLN) attempted to shake nursing schools loose from the hold of the traditional, content-laden, lecture-and-test approach to nursing education. In Curriculum Revolution: Mandate for Change,[5] nursing leaders called for an overhaul of nursing education that would change the way nursing was taught and learned.
It did not succeed. During the ensuing 25 years, under the auspices of "reform," nurse educators essentially re-arranged and updated the curriculum without changing the substance of the curriculum itself or the educational paradigm.[6] In 2003, the NLN once again advocated a transformation of nursing education, via the creation of innovative pedagogies that will be effective in helping students learn to practice in rapidly-changing environments.[6] Graduating nurses would be leaders in health promotion and disease prevention, function in complex and unpredictable environments, demonstrate critical reasoning and flexibility, and execute a variety of roles throughout their nursing careers. The old and tired clinical placement model would give way to an approach that has relevance for the increasingly community-based, multidisciplinary patient care delivery systems of the future.
We now come to 2009. An initiative known as the Future of Nursing (FON), a joint project of the Institute of Medicine and the Robert Wood Johnson Foundation, began its critical review of the nursing profession by holding 3 national forums, one of which focused on nursing education. This forum was led by Michael Bleich, RN, PhD, Dean of the Oregon Health & Science University School of Nursing. Participants in this forum considered needed innovations in what to teach (ideal future nursing curricula), how to teach (methodologies and strategies), and where to teach (venues and locations for nursing education).
The recommendations that came out of this forum were driven by 4 realities (1) more nurses are working outside of hospitals as care shifts formally and informally into communities; (2) evidence that could inform practice is growing rapidly, but is not well-integrated into either education or practice; (3) the need for nurses to effectively work in and lead teams is increasing; and (4) numbers alone will not fill the widening gap between the supply of nurses and the growing need for their services -- additional research and new knowledge will be required.

What Is Missing in Nursing Education?

I had the opportunity to ask Dr. Bleich to summarize the Future of Nursing participants' views on some of the initiative's recommendations to solve the current deficiencies in nursing education.
"Nothing is inherently wrong with the intent of what nursing education is trying to achieve now," explained Dr. Bleich. "We just know more now about how people learn best, knowledge in our field is expanding, and the patients are becoming more complex and challenging to manage. Nurses are being asked to care for more people with complex multiple geriatric syndromes, and this involves more than keeping these patients alive -- it's helping people live their lives to the fullest extent possible. The healthcare organization also expects nurses to perform at a higher level, to participate and contribute to the quality and safety agenda of the organization."
"It's more than knowing how to perform tasks and procedures," continued Dr. Bleich. "It's how to be a more effective player on the healthcare team and navigate clinical systems, and that's not traditionally taught in a classroom. That's a set of experiences that must be added to the way we educate. We need to address concepts within populations of patients, and shift from the medical diagnosis model or the task and procedures model to competence in applying critical concepts to multiple patients with multiple diagnoses."
The Future of Nursing Education report also identifies diversity as a missing element among current nursing student applicants. More racial-ethnic and gender diversity must be actively pursued so that a workforce is created that is better able to meet the demands of a diverse population across the life span, and nurses are better able to provide culturally-relevant care.[1]

Are There Better Ways to Teach and Learn?

Like a telephoto lens, nursing education right now is focused on the individual nurse-patient interaction, but what nurses really need is a panoramic view that encompasses healthcare systems, quality and safety, and a team approach to problem-solving.
Most nursing curricula today are loaded with content and facts to be memorized, in a mostly passive learning environment. Nursing students are rotated through specialties such as obstetrics, pediatrics, and surgery, still following a disease-oriented medical model. Clinical experiences are centered primarily in acute care settings.
The Future of Nursing Education report asserts that today's curriculum is out of date. The organization around discrete medical specialties fails to adequately address care coordination, and the clinical focus on acute care does not prepare nurses for any of the non-hospital roles they might assume upon graduation, such as community health and long-term care. Entry-level nurses need to be able to transition smoothly from their academic preparation to a range of practice environments, with an increased emphasis on non-hospital settings of care.
Nurses must learn how to assess, use, and manage knowledge, rather than trying to pack thousands of facts into their heads, hoping to be able to retrieve them when needed.[2] The Future of Nursing Education report emphasized that "we need to be hardwiring the ability to manage and use knowledge in real time in both education and practice."[2] Knowledge management permits the nurse to access that knowledge with new tools and strategies. Nurse educators need to improve the links between knowledge, clinical reasoning, and practice. The curriculum must emphasize competent performance through active learning.[2]
The Future of Nursing Education reports[1,2] make numerous suggestions for how to improve the standard nursing curriculum. Two of these suggestions are (1) moving toward competency-based learning, and (2) widespread introduction of interprofessional education. Nursing school must also instill in students the spirit of inquiry, so that after graduation from the basic nursing program, lifelong learning continues with continuing nursing education.

Competency-Based Learning

The emphasis in nursing education is sometimes perceived to be on preparing students for their nursing boards, but as Michael Bleich pointed out, "The licensure exam is a minimum standard -- it tests only for minimum safe competency. But the public wants more than that. They want optimal competency, especially in the specialized areas. We have to move beyond the notion of comparing nursing programs for their abilities to assure graduates are minimally competent, and the public is challenging us, and saying how are you going to do this?"
It is a common misconception that competencies are task-based proficiencies. The student demonstrates the ability to take a blood pressure, or give a subcutaneous injection, and the instructor makes a checkmark on a skills list.
Competencies are actually higher level skills that represent the ability to demonstrate mastery over care management and that provide a foundation for decision-making skills under a variety of clinical situations across all care settings. Examples of competencies are:
  • Clinical judgment;
  • Critical reasoning;
  • Evidence-based practice;
  • Relationship-centered care;
  • Interprofessional collaboration and teamwork;
  • Leadership;
  • Assisting individuals and families in self-care practices for promotion of health and management of chronic illness;
  • Teaching, delegation, and supervision of caregivers;
  • Genetics and genomics;
  • Cultural sensitivity;
  • Practice across the lifespan;
  • End-of-life care; and
  • Professionalism.

Interprofessional Education

Interprofessional collaboration, a necessary component of effective care coordination in the increasingly complex healthcare environment, will not be broadly achieved until healthcare professional students are educated together. The poor communication and lack of respect between, for example, nurses and physicians, lead to poor outcomes; but effective teamwork and good working relationships can improve outcomes.
Sharing different professional perspectives is viewed as critical to this objective.[1] This will only be achieved through interprofessional team training of nurse, physician, and other healthcare provider students, and this in turn requires committed partnerships across the professions.[1] Nursing and medical students who are educated in interprofessional collaboration, knowledge of each other's professional roles and responsibilities, effective communication, conflict resolution, and shared decision-making, and who are exposed to the other students through simulation and Web-based training, will be more likely to engage in collaboration in future work settings.[1]
It is recommended that schools of nursing and other health professional schools should implement early and continuous interprofessional collaboration through joint classroom and clinical training opportunities. Interprofessional education should continue after these students begin working through joint continuing competency programs provided by healthcare organizations.

Continuing Education

Not a single initial degree can provide a nurse with all she or he will need to know over an entire career.[1] Students need to learn the fundamentals of their profession, but they also need to develop a "spirit of inquiry."[2]
"We need nurses to engage in lifelong learning," explained Dr. Bleich. "This is not just what they learn on the job caring for patients, or at skills fairs, but professional development, continuing education, and stretching leadership development. It doesn't always require another professional degree, but neither is it what is casually or serendipitously picked up during the course of delivering care, either."
The Future of Nursing initiative identified a framework for continuous lifelong learning that includes basic education, academic progression, and continuing competencies. Nurses need a solid education in how to manage complex conditions and coordinate with other healthcare professionals. New competencies in systems thinking, quality improvement, care management, and a basic understanding of healthcare policy must be demonstrated.[1]

Nursing Degrees: What's in Their Future?

Nursing is unique among the healthcare professions in the United States in that multiple educational pathways lead to an entry-level license to practice.[1] A key recommendation of the Future of Nursing initiative was that all nursing schools should offer defined academic pathways that promote seamless access for nurses to higher levels of education.[1]
The nursing diploma. Once the most popular route to becoming a nurse, the hospital-based nursing diploma program has been all but phased out in the United States. Among still licensed RNs, 20% received a hospital diploma for their initial "nurses training," but this number is steadily declining.[7] Only 3.1% of registered nurses who graduated after 2004 were educated in a diploma program.
It is believed that diploma programs should be phased out over the next 10 years and, their resources consolidated with schools providing AD or preferably, BS degrees.[1]
The associate's degree in nursing. As of 2008, the Associate's Degree in Nursing (ADN) was still the most common initial nursing education degree, earned by 45% of all licensed registered nurses.[7] A common misconception exists that the AD is a 2-year degree; whereas, in nursing, the ADN usually takes at least 3 years to complete because of course prerequisites.[1] In the United States, 21% of nurses who initially earn an ADN go on to earn higher nursing degrees.[7] Many rural and other medically underserved communities would not be able to staff their hospitals, clinics, and long-term care facilities without ADN prepared nurses.
I asked Dr. Bleich if the ADN degree will still have a place in the hierarchy of nursing education. He explained that "it's an important entry point for many nurses, a portal to get into nursing as a career, but it shouldn't be a terminal degree. We did address the role of the ADN nurse, but were more focused on the public's need for expanded nursing competencies and this translates into nurses obtaining higher education and not stopping at the associate's level. The need for education and development of the nurse if far greater -- we need more advanced practice nurses, more faculty, more nursing leaders."
Healthcare organizations need to step up and encourage nurses with ADN (and diploma) degrees to enter baccalaureate nursing programs within 5 years of graduation by offering tuition reimbursement, creating a culture that fosters continuing education, and providing salary differentials and promotion opportunities.[1]
Hand-in-hand with the future of the ADN degree is the future of nursing education in community colleges. In rural and medically underserved areas, most nursing education takes place in these settings. The Future of Nursing initiative believes that community colleges must either join an educational collaborative or develop innovative and easily accessible programs that seamlessly connect students to schools offering the BSN and higher degrees, or if possible, develop their own BSN programs.[1]
The bachelor's degree/baccalaureate. Only approximately 34% of nurses (in 2008) had received their initial nursing education in a bachelor's program, but 50% of licensed nurses eventually earned a bachelor's degree.[7] Despite an average gap of 10.5 years before nurses with an AD or diploma earned their bachelor's degrees, this reflects the recognition on the part of many nurses that higher degrees are important for professional and career development.
The goal established by the Future of Nursing initiative is to increase the proportion of nurses with a baccalaureate degree to 80% by the year 2020.[2] Furthermore, at least 10% of these baccalaureate graduates must matriculate into a master's or doctoral program within 5 years of graduation.[1]
Increasing the percentage of nurses with a BSN degree is in line with what the public needs from nurses in terms of growing expectations for quality, and as the settings where nurses are needed proliferate and become more complex.[1] More BSN nurses will be necessary to expand competencies in areas such as community and public health, leadership, systems improvement and change, research, and health policy; and to provide a pool of potential candidates to move on to master's and doctoral education in nursing.
The American Organization of Nurse Executives and the American Association of Colleges of Nursing have called for a mandated baccalaureate degree as a point of entry to nursing practice.[8] Studies demonstrate better patient outcomes in hospitals staffed by a greater proportion of nurses with baccalaureate degrees to those with associate degrees.[8]
The master's degree. Currently, 13.2% of licensed registered nurses hold a master's, or higher, degree.[7] These nurses work in a variety of roles, including clinical nurse specialist, nurse practitioner, nurse midwife, and nurse anesthetist. Master's degrees prepare RNs for leadership roles -- in administration, clinical, or teaching -- or for work in other advanced practice roles, and serve as a springboard to doctoral pursuits.
The fate of the master's degree depends in part on whether consensus is reached on requiring the doctoral degree for entry into advanced practice. At this time, however, the Future of Nursing Education group did not think that the evidence was sufficient to require the doctoral degree for entry into advanced practice nursing.[2] Therefore, other than increasing the numbers of nurses who earn a master's degree, no specific recommendations were made about the master's degree in nursing.
The doctoral degree. The current goal is to double the number of doctorally prepared nurses by 2020. Two primary degrees in nursing at this level are the PhD and the DNP (doctor of nursing practice). The latter has been increasing in popularity throughout the last decade. A shortage of nurses prepared at the highest levels of education and working in primary care, education, and research is viewed as a barrier to advancing the profession of nursing and improving the delivery of care to patients.[1]
Dr. Bleich spoke about the concern that the rise in numbers of nurses obtaining a practice doctorate (rather than the PhD) will influence the growth of nursing research, and if we will have enough PhDs to sustain and expand nursing research? "Newly emerging data suggest that this is not the case," replied Dr. Bleich." It's true that nurses who seek the DNP usually don't want to be researchers, but anecdotally, through their education, some are becoming attracted to the PhD. The DNP is engaging nurses in research and inquiry."

Why Go Back to School?

I asked Dr. Bleich why, considering the expense and time commitment, should nurses go back to school for another degree? For example, if I have an associate's degree, why do I need to get my bachelor's?
"It starts with one's personal desire to develop oneself -- investing in oneself is a fundamental tenet of a professional. We live in a time when knowledge is exploding, technology is adding complexity to our work, and there are more opportunities for nurses to work in more settings than we've ever known in the history of nursing (Table). Many organizations are expecting more highly educated nurses. The public also wants nurses to be more knowledgeable and more adept. This is part of the nurse's reality."
Table. Nontraditional Nursing Careers
Transitional Care Nurse
Care Manager/Coordinator
Telehealth Nursing
Nursing Informatics
Forensic Nurse
Legal Nurse Consultant
Hospice Nurse
Palliative Care Nurse
Nurse Epidemiologist
Occupational Health Nurse
Travel Health Nurse
Cruise Ship Nurse
RN Operating Room First Assistant
Wound Care Nurse

From Olmstead J. Nurs Manage. 2009;40:52.[9]

Does Nursing Education Prepare Nurses for the Real World?

In a descriptive survey design, Candela and Bowles[10] asked 352 recent nursing school graduates how well their educational programs had prepared them for their first jobs as registered nurses, and what, if any, did they identify as the inadequacies in their education? These recent graduates said they were inadequately prepared in pharmacology, clinical practice, leadership, and the use of patient electronic medical records. Most believed that their programs prepared them more for success on the NCLEX-RN exam than for practice.
To be fair, nursing school is about more than preparing a nurse for his or her first job. It's about preparing nurses for a profession -- a lifetime career.
It's possible that the right balance between the two hasn't yet been found, or that other strategies are needed to facilitate the transition to the nurse's "first job." This need was addressed by the Future of Nursing initiative.[1]

Future of Nursing Recommendation: Residency Programs

A key recommendation of the Future of Nursing initiative is to broaden the use of nurse residency programs.[1] Residencies are transitional programs, designed both for new graduates and for experienced nurses who wish to change practice settings. A residency provides time for the nurse to perfect competencies in a new environment.
Residencies are needed because schools of nursing prepare pre-licensure graduates as generalists.[2] Even with a sound theoretical foundation, novice nurses are not prepared with the knowledge and skill base for practice with specific populations. They need to be able to apply that knowledge and develop situation decision making skills. A residency is a transition to practice period, generally thought to require at least 1 year, that gives the new nurse a period of mentored supervision and support.
Healthcare organizations should provide residency programs, not only for new graduate nurses, but also for nurses who have completed advanced practice degree programs or nurses who are transitioning into new clinical practice areas as a career move.[1] Residency programs should also take place in community care settings.

The Imperative to Change the Educational Paradigm

As a profession, nursing is moving beyond the objective of simply increasing its numbers, to positioning itself in a healthcare environment that is being transformed to meet the needs of society for higher quality, safer, more affordable and more accessible healthcare. The emphasis on health promotion, illness prevention, and provision of care to diverse populations throughout the lifespan must be incorporated not only into practice, but also into education.
"Nursing roles must change to meet the public's demand for us in the future. The public wants to know that the nurses who are providing care are competent." explains Dr. Bleich. "There is a tsunami of people coming into the healthcare system at the upper echelons of age, with multiple diagnoses and chronic conditions. We need to reshape the healthcare system so that we can intervene outside of the traditional sick care system. We just have to know more."


  1. Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing, at the Institute of Medicine; Institute of Medicine. The Future of Nursing: Leading Change, Advancing Health. Washington DC: National Academies Press; 2011.
  2. Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing, at the Institute of Medicine. A Summary of the February 2010 Forum on the Future of Nursing: Education. Washington DC, National Academies Press, 2010. Available at: Accessed January 21, 2011.
  3. Schryver GF. A History of the Illinois Training School for Nurses, 1880-1929. Chicago, IL: The Board of Directors of the Illinois Training School for Nurses, 1930. Available at: Accessed January 21, 2011.
  4. National League for Nursing Education. Standard Curriculum for Schools of Nursing. Baltimore, Md: Waverly Press; 1919. Available at: Accessed January 21, 2011.
  5. National League for Nursing. Curriculum Revolution: Mandate for Change. New York: NLN Publications; 1988.
  6. National League for Nursing. Innovation in Nursing Education: A Call to Reform. New York: NLN Publications; 2003. Available at: Accessed January 21, 2011.
  7. US Department of Health and Human Services. Health Resources and Services Administration. The registered nurse population. September, 2010. Available at: Accessed January 21, 2011.
  8. Benner P, Sutphen M, Leonard V, Day L. Educating Nurses: A Call for Radical Transformation. Hoboken, NJ: Jossey-Bass; 2009.
  9. Olmstead J. The road less traveled: nontraditional nursing careers. Nurs Manage. 2009;40:52.
  10. Candela L, Bowles C. Recent RN graduate perceptions of educational preparation. Nurs Educ Perspect. 2008;29:266-271. Abstract


Monday, August 27, 2012

Feeding Quiz

 Feeding Quiz

1.      If a resident is choking on food and is coughing strongly, what do you do?
Wait and allow them to cough

2.      If your resident has a feeding tube, what do you do with the bed?
       Elevate the head of the bed at least 45 degrees during feeding

3.      When you are helping a resident to eat, what type of position do you place them in?
Seat them comfortably in an upright position

4.      If a person coughs each time they drink fluids, what do you think is the issue?

5.      If a resident is supposed to receive supplemental feedings, liquid or solid, who offers it to the resident?
The nursing assistant’s responsibility

6.      If my resident has right-sided paralysis, and I am feeding him, the food should be placed where?
On the left side of the mouth or on the unaffected side of the tongue

7.      After feeding a resident who has aspiration precautions, the head of the bed should be placed how?
          Elevated greater than 30 degrees

8.      When I feed a resident, how should I stand?
At eye level

9.      What is the CNA’s first reaction when a feeding infusion pump is beeping?
        Notify the nurse

10.  When feeding a resident after a CVA, the CNA should…
Test the temperature of the food and feed with small bites

11.  How long should you leave the HOB up after a tube feeding has ended?
Leave the head of the bed up for one hour

12.   Do frequent oral care on a resident who has a feeding tube…
Give frequent oral hygiene to a resident who has  a tube feeding

13.   Does the CNA disconnect the feeding tube prn?
Using extreme care when repositioning the resident

14.   What is a serious problem for a resident with diarrhea?

Wednesday, August 15, 2012

In ill doc, surprising reflection of who chooses assisted suicide

In ill doc, surprising reflection of who chooses assisted suicide

Leah Nash for The New York Times
Dr. Richard Wesley, who received a diagnosis of Lou Gehrig’s disease in 2008, at home with his wife and two of his children.
Dr. Richard Wesley has amyotrophic lateral sclerosis, the incurable disease that lays waste to muscles while leaving the mind intact. He lives with the knowledge that an untimely death is chasing him down, but takes solace in knowing that he can decide exactly when, where and how he will die.
Under Washington State’s Death With Dignity Act, his physician has given him a prescription for a lethal dose of barbiturates. He would prefer to die naturally, but if dying becomes protracted and difficult, he plans to take the drugs and die peacefully within minutes.
“It’s like the definition of pornography,” Dr. Wesley, 67, said at his home here in Seattle, with Mount Rainier in the distance. “I’ll know it’s time to go when I see it.”
Washington followed Oregon in allowing terminally ill patients to get a prescription for drugs that will hasten death. Critics of such laws feared that poor people would be pressured to kill themselves because they or their families could not afford end-of-life care. But the demographics of patients who have gotten the prescriptions are surprisingly different than expected, according to data collected by Oregon and Washington through 2011.
Dr. Wesley is emblematic of those who have taken advantage of the law. They are overwhelmingly white, well educated and financially comfortable. And they are making the choice not because they are in pain but because they want to have the same control over their deaths that they have had over their lives.
While preparing advance medical directives and choosing hospice and palliative care over aggressive treatment have become mainstream options, physician-assisted dying remains taboo for many people. Voters in Massachusetts will consider a ballot initiative in November on a law nearly identical to those in the Pacific Northwest, but high-profile legalization efforts have failed in California, Hawaii and Maine.

Oregon put its Death With Dignity Act in place in 1997, and Washington’s law went into effect in 2009. Some officials worried that thousands of people would migrate to both states for the drugs.
“There was a lot of fear that the elderly would be lined up in their R.V.’s at the Oregon border,” said Barbara Glidewell, an assistant professor at Oregon Health and Science University.
That has not happened, although the number of people who have taken advantage of the law has risen over time. In the first years, Oregon residents who died using drugs they received under the law accounted for one in 1,000 deaths. The number is now roughly one in 500 deaths. At least 596 Oregonians have died that way since 1997. In Washington, 157 such deaths have been reported, roughly one in 1,000.
In Oregon, the number of men and women who have died that way is roughly equal, and their median age is 71. Eighty-one percent have had cancer, and 7 percent A.L.S., which is also known as Lou Gehrig’s disease. The rest have had a variety of illnesses, including lung and heart disease. The statistics are similar in Washington.
  1. There were fears of a “slippery slope” — that the law would gradually expand to include those with nonterminal illnesses or that it would permit physicians to take a more active role in the dying process itself. But those worries have not been borne out, experts say.
Dr. Wesley, a pulmonologist and critical care physician, voted for the initiative when it was on the ballot in 2008, two years after he retired. “All my career, I believed that whatever makes people comfortable at the end of their lives is their own choice to make,” he said.
But Dr. Wesley had no idea that his vote would soon become intensely personal.
In the months before the vote, he started having trouble lifting weights in the gym. He also noticed a hollow between his left thumb and index finger where muscle should be. A month after casting his vote, he received a diagnosis of A.L.S. Patients with the disease typically live no more than four years after the onset of symptoms, but the amount of time left to them can vary widely.
In the summer of 2010, after a bout of pneumonia and with doctors agreeing that he most likely had only six months to live, Dr. Wesley got his prescription for barbiturates. But he has not used them, and the progression of his disease has slowed, although he now sits in a wheelchair that he cannot operate. He has lost the use of his limbs and, as the muscles around his lungs weaken, he relies increasingly on a respirator. His speech is clear, but finding the air with which to talk is a struggle. Yet he has seized life. He takes classes in international politics at the University of Washington and savors time with his wife and four grown children.
In both Oregon and Washington, the law is rigorous in determining who is eligible to receive the drugs. Two physicians must confirm that a patient has six months or less to live. And the request for the drugs must be made twice, 15 days apart, before they are handed out. They must be self-administered, which creates a special challenge for people with A.L.S.
Dr. Wesley said he would find a way to meet that requirement, perhaps by tipping a cup into his feeding tube.
The reasons people have given for requesting physician-assisted dying have also defied expectations.
Dr. Linda Ganzini, a professor of psychiatry at Oregon Health and Science University, published a study in 2009 of 56 Oregonians who were in the process of requesting physician-aided dying.
“Everybody thought this was going to be about pain,” Dr. Ganzini said. “It turns out pain is kind of irrelevant.”
At the time of each of the 56 patients’ requests, almost none of them rated pain as a primary motivation. By far the most common reasons, Dr. Ganzini’s study found, were the desire to be in control, to remain autonomous and to die at home. “It turns out that for this group of people, dying is less about physical symptoms than personal values,” she said.
The proposed law in Massachusetts mirrors those in Oregon and Washington. According to a telephone survey conducted in May by the Polling Institute at Western New England University, 60 percent of the surveyed voters supported “allowing people who are dying to legally obtain medication that they could use to end their lives.”
“Support isn’t just from progressive Democrats, but conservatives, too,” said Stephen Crawford, a spokesman for the Dignity 2012 campaign in Massachusetts, which supports the initiative. “It’s even a libertarian issue. The thinking is the government or my doctor won’t control my final days.”
Such laws have influential opponents, including the Roman Catholic Church, which considers suicide a sin but was an early leader in encouraging terminal patients to consider hospice care. Dr. Christine K. Cassel, a bioethicist who is president of the American Board of Internal Medicine, credits the church with that effort. “But you can see why they can go right up to that line and not cross over it,” she said.
The American Medical Association also opposes physician-assisted dying. Writing prescriptions for the drugs is antithetical to doctors’ role as healers, the group says. Many individual physicians share that concern.
“I didn’t go into medicine to kill people,” said Dr. Kenneth R. Stevens, an emeritus professor of radiation oncology at Oregon Health and Science University and vice president of the Physicians for Compassionate Care Education Foundation.
Dr. Steven Kirtland, who has been Dr. Wesley’s pulmonologist for three years, said he had little hesitation about agreeing to Dr. Wesley’s request, the only prescription for the drugs that Dr. Kirtland has written.
“I’ve seen a lot of bad deaths,” Dr. Kirtland said. “Part of our job as physicians is to help people have a good death, and, frankly, we need to do more of that.”
Story: Hospital shooting: Mercy killing or murder?
Dr. Wesley’s wife, Virginia Sly, has come to accept her husband’s decision. Yet she does not want the pills in the house, and he agrees. “It just feels so negative,” she said. So the prescription remains at the pharmacy, with the drugs available within 48 hours.
There are no studies of the psychological effect of having a prescription on hand, but experts say many patients who have received one find comfort in knowing they have or can get the drugs. About a third of those who fill the prescription die without using it. “I don’t know if I’ll use the medication to end my life,” Dr. Wesley said. “But I do know that it is my life, it is my death, and it should be my choice.”
This article, “ In Ill Doc, A Surprising Reflection of Who Picks Assisted Suicide,” first appeared in The New York Times.

What is wrong with people

Records show troubles for ‘waterboarding’ doctor
Court records • Police say Melvin Morse may have been experimenting on his daughter.
FILE - Melvin L. Morse is seen in an undated file photo provided by the Delaware State Police. Morse, 58, of Georgetown, Del., and his wife, Pauline Morse, were arrested Tuesday, Aug. 7, 2012 by Delaware State Police and charged with recklessly endangering their two daughters, including the use of a form of discipline that police say the man called “waterboarding.” Morse says he is being persecuted by authorities because of a 2009 doctor abuse scandal in the state. Dr. Melvin Morse tells The Associated Press that he is the victim of what he called hysteria following the prosecution of pediatrician Earl Bradley. Bradley is serving 14 life sentences for abusing scores of his young patients over more than a decade. (AP Photo/Delaware State Police, File)
Dover, Del. • To many people, Melvin Morse was a brilliant pediatrician at a renowned children’s hospital and a best-selling author who parlayed his research on near-death experiences into appearances on “Larry King Live” and “The Oprah Winfrey Show.”
Away from the spotlight, however, Morse was tormented by personal and financial problems and, according to court records, wrestled with depression, substance abuse and even suicidal thoughts. His latest trouble involves allegations of waterboarding his 11-year-old stepdaughter, using the simulated drowning technique to bring her to “a possible near-death state,” police have said.
Based on his work involving children’s near-death experiences, police suggested he may have been experimenting on her.
Morse, 58, was accused in July of grabbing his daughter by the ankle and dragging her across a gravel driveway. When police did a follow-up interview last week, the girl said Morse had held her face under running water at least four times since 2009, using faucets in the kitchen, bathroom sink and bathtub. Her mother, Pauline Morse, witnessed some of the waterboarding but did nothing to stop it, police said.
Both Melvin and Pauline Morse are free on bail. They face a preliminary hearing Thursday on felony endangerment and conspiracy charges.
In an interview with The Associated Press, Melvin Morse called the charges an overreaction by authorities. An attorney for Morse, Joe Hurley, said the idea that Morse was experimenting on his own daughter was “the sheerest of speculation.”
Morse began researching near-death experiences in children about three decades ago after the near drowning of one of his patients. He was fascinated by the spiritual experiences the girl, and other children, described to him, including images of light, heaven and tunnels.
He sought to prove that drugs were causing the hallucinations, though he said his research proved otherwise. In 1990, he published “Closer to the Light,” which spent several weeks on the New York Times bestseller list. He was featured in a Rolling Stone magazine story, and television shows had him on to speak about paranormal experiences.
He worked for Seattle Children’s Hospital and Seattle Magazine listed Morse among the city’s best doctors for more than a decade beginning in 1995, according to Morse’s website. But by 2007, Morse had retired from full-time medical practice and moved to Delaware. Hepatitis C that he contracted in 1998 while treating children became too much of a toll on his health for him to continue working full time and he was declared disabled, he said.
While Morse once earned a six-digit income, he has struggled financially for years and owes tens of thousands of dollars in back taxes.
“I have the most ordinary reasons for that — the collapse of my income and my first divorce,” Morse said. “I do not have an adversarial relationship with the IRS. ... I’ll eventually repay my taxes.”
Morse’s financial problems are outlined in court records from a contentious divorce and custody battle with his first wife that stretched on for nearly a decade.
Morse’s ex-wife, Allison Morse, claimed her ex-husband has abused prescription drugs and made false accusations against their adopted children that have led to criminal charges against them.
“He is a pathological liar and he makes stuff up about his own children,” she told the AP.
At the same time, Allison said Morse was a good dad and never abused their three adopted children during their marriage of almost 20 years.
As the marriage began to unravel in the late 1990s, however, he became more and more emotionally unstable, she said.
“He was just angry all the time and just really had some severe emotional problems going on,” she said.
Allison said she was never able to find out why her husband was so troubled.
In 2006, Morse said in court papers he was once the subject of an inquiry by the Medical Quality Assurance Commission in Washington, which he blamed on stress from his marital problems. Morse said he accepted three months of psychiatric treatment.
In that same court filing, he denied that he had a history of multiple suicide attempts but said he made a “suicide gesture” when his marriage was falling apart by swallowing prescription pills.
In separate court filings, Morse referred to an earlier suicide attempt and being taken to an emergency room in November 2001 for “drug overdose, alcoholism, and depression.”
Morse has published several books over the years, and writings include a quasi-autobiographical story in which he describes how an imaginary falcon told him to move “quickly in the dark of night” to the East Coast, where his destiny lay and where he could find rich soil for his “BIG IDEA” to grow.
Morse, who said he uses “a lot of irony and a lot of tongue-in-cheek” expressions when he writes, told the AP his “BIG IDEA” involved a theory of consciousness based on his study of children who have suffered cardiac arrest.
“These children made it clear that consciousness persists despite having dying, dysfunctional brains,” he said. The theory is that brains are linked to “a non-local consciousness and a timeless, spaceless reality,” which Morse calls the “God Spot.”
Morse currently lives with Pauline Morse in Delaware with their two children, the 11-year-old girl and her 6-year-old sister. Their marriage was at one point dissolved, and it’s not clear if they remarried. Their children have been placed in state custody.
Just before Melvin Morse’s arrest last month, P.M.H. Atwater, a fellow researcher into near-death experiences, said she saw him at a conference in Montreal.
“He gave one of the best keynote addresses he has ever given in his life,” she said.
But when she went to hug Morse, Atwater sensed something was wrong.
“I just picked up a lot of worry, a lot of stress, a lot of problems,” she said.

Don't have sex with the lunch lady

Jury, not judge, to hear case of Utah lunch lady accused of sexual assault
Utah Supreme Court • Ruling granting trial by judge overturned.
Jamie Lynn Greenwood
More than two years after her arrest, a middle-school cafeteria worker accused of sexually assaulting a 16-year-old boy looks to be headed to trial in front of a jury.
The Utah Supreme Court on Thursday ruled against 43-year-old Jamie Lynn Greenwood, who wanted her case heard by a judge instead of a jury.
Prosecuters cried foul when Greenwood, on the morning her jury trial was to begin in August 2010, asked 3rd District Court Judge Robert Adkins to hear her case instead. Her attorney argued a trained legal mind would be better able to parse the fine line between, for example, rape and unlawful sexual activity, and that the jury pool was tainted by pretrial publicity.
Adkins granted the request and the prosecution appealed to the Utah Supreme Court.
In an opinion released Friday, the high court sided with the state, ruling that case law establishes defendants don’t have the right to choose a judge over a jury if prosecutors don’t sign off.
“A district court cannot disregard clearly established law merely because it disagrees with it,” the justices wrote, slamming Adkins’ ruling, adding they were “confident,” Greenwood could get an impartial trial by jury.
Greenwood is accused of demanding sex acts from her son’s friend and classmate in return for gifts, like an iPod, cologne and money. She allegedly made threats at various times to tell people at school or leave the boy in an unfamiliar neighborhood when he tried to stop or avoid the abuse.
Greenwood, a cafeteria worker at Eastmont Middle School in Sandy for four years until she resigned due to the allegations, claimed the relationship was consensual, and the boy “threatened and intimated” her into having sex.
She is charged with two counts of rape and two counts of forcible sodomy, all first-degree felonies, and forcible sexual abuse, a second-degree felony.
Greenwood has remained free for the past two years after posting $10,000 bail.
lwhitehurst@sltrib.comTwitter: @lwhitehurst
What’s next
Former cafeteria worker Jamie Lynn Greenwood has a review hearing set at 8:30 a.m. on Aug. 23. A new trial date has not been set.

© 2012 The Salt Lake Tribune

Wednesday, August 8, 2012

Why do I need to know what time it is

Claudine was helping a student learn to take a pulse. Claudine kept telling her to look at her watch. Exasperated the student said "WHY DOES EVERYONE KEEP TELLING ME TO LOOK AT MY WATCH WHEN I TAKE A PULSE. WHAT DIFFERENCE DOES IT MAKE WHAT TIME IT IS?"

Tuesday, August 7, 2012

What the US Needs Now: Pertussis Boosters

 Paul A. Offit, MD
Professor, Department of Pediatrics, University of Pennsylvania School of Medicine; Chief, Division of Infectious Diseases, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania

Disclosure: Paul A. Offit, MD, is the coinventor of the RotaTeq® vaccine, but he receives no financial remuneration for sales of the vaccine from either the manufacturer or his employing institution.

From Medscape Infectious Diseases > Offit on Vaccines

What the US Needs Now: Pertussis Boosters

Not Just for Some, but for Everyone

 My name is Paul Offit. I am speaking to you today from the Vaccination Education Center at Children's Hospital of Philadelphia. It is July 27, 2012, and I would like to talk about an article that appeared recently in Morbidity and Mortality Weekly Report [1] discussing an outbreak of pertussis (whooping cough) that has occurred in Washington State.

As of today, 3000 cases of pertussis have been reported in Washington State. Although there have been no deaths, this is the biggest outbreak seen there in 50 years. It is just a microcosm of what has been going on in the country because 18 states are in the midst of epidemics of pertussis. We have had a total of approximately18,000 cases of pertussis this year, including 9 deaths, and we are only halfway through the year. This could be one of the biggest outbreaks of pertussis we have had in decades.
So, the question is, why? To understand that, we need to go back to the beginning. The original pertussis vaccine was developed by Pearl Kendrick and Grace Eldering in the 1930s. It came into widespread use by the early 1940s. Kendrick and Eldering made the original vaccine by growing Bordetella pertussis in media. They then treated it with formaldehyde, and basically this produced inactivated pertussis toxins (otherwise known as toxoids) as well as structural and nonstructural proteins of the bacteria.
There were about 3000 immunologic components in that vaccine, counting bacterial proteins as well as bacterial polysaccharides, with toxins being considered bacterial protein. It was a highly immunogenic vaccine. Pertussis is a disease that killed more children in the 1940s than did polio, measles, and tuberculosis combined. In the United States, pertussis killed as many as 8000 children every year. With the advent of the vaccine, we saw a dramatic decline in the incidence of pertussis.
In 1997, we switched from the whole bacterial vaccine to the acellular vaccine. We took advantage of advances in protein chemistry and protein purification to make a purer and safer vaccine, because the whole-cell vaccine had a difficult side-effect profile. Episodes of seizures, including seizures with fever, were not infrequent. There was high fever and persistent and inconsolable crying. There was hypotonic hyporesponsive syndrome, which was dramatically reduced by the advent of the acellular vaccine. We are now about 15 years into that vaccine.
However, the acellular vaccine is less effective. To some extent, we have traded efficacy for safety. We are now finding out just how big a trade that was. When you look at the outbreak in Washington State, you can see that waning immunity is a significant reason that we are seeing these outbreaks.
What should we do? There are 2 ways of looking at this. One is to know that the most effective weapon we have to prevent pertussis is still the pertussis vaccine and especially the Tdap [tetanus, diphtheria, pertussis] component given as a booster to older adolescents and adults. If you look at who dies of pertussis, it is young infants -- children less than a few months of age. They are not going to be protected by pertussis vaccine anyway. The best way for them to be protected is by immunizing their mothers.
Mothers are recommended to receive the Tdap vaccine either in the late second trimester or the third trimester of pregnancy. However, many mothers don't get that vaccine. The second recommendation is to make sure that adults living in the home or older children living in the home have received a Tdap booster.
With the outbreak that occurred in California in 2010, people were 8 times less likely to get pertussis if they had received the Tdap vaccine than if they hadn't. Similarly, the Tdap vaccine lessens the degree of illness, even though it may still develop. People are much less likely to get moderate-to-severe disease if they have been vaccinated.
Current immunization rates in adults are about 8%. That is woeful. The best thing we can do right now is to make sure that everyone who is living in a home with young children is vaccinated, especially adults. Thank you.


  1. DeBolt C, Tasslimi A, Bardi J, et al. Pertussis epidemic - Washington, 2012. MMWR Morb Mortal Wkly Rep. 2012;61:517-522. Accessed July 27, 2012.

Once Promising Alzheimer's Drug Scrapped By Pfizer, Johnson & Johnson

Once Promising Alzheimer's Drug Scrapped By Pfizer, Johnson & Johnson
Trials of a once-promising treatment for Alzheimer’s disease have been scrapped by two pharmaceutical giants after clinical results showed that the drug wasn’t working.

Pfizer and Johnson & Johnson announced late Monday that they were ending human trials of the drug bapineuzumab.

The drug, which was tailored to moderately to severely afflicted victims of a certain genotype, had raised hopes because it purported to work on the cause of Alzheimer’s and not just its ravages.

Bapineuzumab had been designed to block the buildup of beta amyloid protein plaques in patients without the genotype APOE4.

But the drug didn’t meet its endpoints for cognitive and functional performance in its patients, the companies said. So it’s back to the drawing board for researchers—and the millions of Alzheimer’s sufferers.

“We are obviously very disappointed in the outcomes of this trial,” Pfizer Senior Vice President Steven Romano said in a news release on the company’s website. “We are also saddened by the lost opportunity to provide a meaningful advance for patients afflicted with mild to moderate Alzheimer’s disease and their caregivers.”

Eric Hall, president and chief executive officer of the Alzheimer’s Foundation of America, said he hoped that the latest setback will only act as a challenge and that scientists, political leaders, and families will redouble their efforts to find a way out of the Alzheimer’s labyrinth.

“There is no doubt that each promising clinical trial that fails to materialize dashes hopes,” Hall said in a news release sent by a spokeswoman. “But this disappointment also re-emphasizes the need to rally around this public health crisis. “Scientists need to keep going,” he added, “and research dollars as well as participation in clinical trials must increase to align with the escalating scope of this disease. Moreover, funding and enhancement of care-related programs and services must become a priority to address immediate direct care needs. Now is the time for all of us to press forward to ensure that advances related to both cure and care come to the rescue of families worldwide.”